Treatment of Progressive Systemic Sclerosis with Plasma Exchange. Seven Cases

Seven patients, 4 women and 3 men afflicted with severe progressive systemic sclerosis (PSS) were treated with Plasma Exchange after failure of different other treatment. All patients presented Raynaud phenomenon and arthritis, 6 patients presented extensive skin lesions, 5 of them digestive manifestations, 3 pulmonary fibrosis. In one case PSS was associated with polymyositis, one patient presented bilateral recurrent cornea ulcerations, (Sjögren Syndrom) and one patient numerous skin ulcerations. In 5 patients adjuvant corticosteroid therapy was given during the course of PE.

In 3 patients PE must be stopped after one or two sessions because of insufficient venous access.

Among the 4 other patients 8 to 20 PE were performed: the patient with cornea ulcerations became blind during the treatment, skin ulcerations and severe Raynaud phenomenon did not improved in two other patients. Benefit of PE was noted in only one patient with regressive myositis, and improvement of articular and cutaneous symptoms.

Therefore, PE are not useful in most patients afflicted with PSS, they are difficult to realize in numerous patients and did not improve clinical symptoms in most cases.

Intérêt de la tomographie par émission de positons couplée au scanner dans la maladie d'Erdheim-Chester

INTRODUCTION

Erdheim-Chester disease is a rare non-Langerhans form of histiocytosis. We report the use of combined fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET-CT) in this disease.

EXEGESIS

Three men, aged from 55 to 74 years with confirmed Erdheim-Chester disease were included. 18F-FDG PET-CT allowed to detect visceral and vascular involvement of the disease which were overlooked with CT-scan or magnetic resonance imaging: left common carotid and ilio-femoral artery in one patient, coronary, femoral and tibia in the second, aortic, common carotid, femoral and mandibula in the remaining patient. Also, sequential 18F-FDG PET-CT was useful to appreciate treatment efficiency (decrease hyperfixation) and decide treatment modification (interferon alpha).

CONCLUSION

18F-FDG PET-CT combined imaging allows to assess the extent of involvement in Erdheim-Chester disease. 18F-FDG PET-CT may be also a useful tool in the management of Erdheim-Chester disease.

Molecular characterization of the idiopathic hypereosinophilic syndrome (HES) in 35 French patients with normal conventional cytogenetics

Idiopathic hypereosinophilic syndrome (HES) characterized by unexplained and persistent hypereosinophilia is heterogeneous and comprises several entities: a myeloproliferative form where myeloid lineages are involved with the interstitial chromosome 4q12 deletion leading to fusion between FIP1L1 and PDGFRA genes, the latter acquiring increased tyrosine kinase activity. And a lymphocytic variant, where hypereosinophilia is secondary to a primitive T lymphoid disorder demonstrated by the presence of a circulating T-cell clone. We performed molecular characterization of HES in 35 patients with normal karyotype by conventional cytogenetic analysis. TCRgamma gene rearrangements suggesting T clonality were seen in 11 (31%) patients, and FIP1L1-PDGFRA by RT-PCR in six (17%) of 35 patients, who showed no evidence of T-cell clonality. An elevated serum tryptase level was observed in FIP1L1-PDGFRA-positive patients responding to imatinib, whereas serum IL-5 levels were not elevated in T-cell associated hypereosinophilia. Sequencing FIP1L1-PDGFRA revealed scattered breakpoints in FIP1L1-exons (10-13), whereas breakpoints were restricted to exon 12 of PDGFRA. In the 29 patients without FIP1L1-PDGFRA, no activating mutation of PDGFRA/PDGFRB was detected; however; one patient responded to imatinib. FISH analysis of the 4q12 deletion was concordant with FIP1L1-PDGFRA RT-PCR data. Further investigation of the nature of FIP1L1-PDGFRA affected cells will improve the classification of HES.

A study of 75 pregnancies in patients with antiphospholipid syndrome

OBJECTIVE

To describe a French tertiary referral center experience in the treatment of pregnancies in patients with the antiphospholipid syndrome (APS).

METHODS

Retrospective review of the data of 75 consecutive pregnancies in 47 women.

RESULTS

After exclusion of induced abortions and pregnancies occurring before APS onset, the prior live birth rate was 7.9%. Forty-nine pregnancies occurred in women with history of vascular thrombosis, 17 with history of thrombocytopenia. Heparin was prescribed in 39 pregnancies, associated with aspirin in 35 cases, and aspirin alone was used in 36 as first-line therapy. Corticosteroids were prescribed in 38 pregnancies. Three pregnancies by in vitro fertilization led to one embryonic loss, one full term birth, and one premature birth. Six pregnancies treated with immunoglobulin ended in one fetal death, 2 premature and 3 full term deliveries. The outcome of the other 66 pregnancies was one embryonic loss, 8 fetal deaths, 16 prematurates, and 38 full term births. Use of corticosteroids correlated with severe prematurity (p = 0.005), preeclampsia (p = 0.014), intrauterine growth retardation (p = 0.005), and presence of disease associated to APS (p = 0.009). After exclusion of one fetal death associated with congenital anomaly, live birth rate was 72.9%. There was a trend for higher rate of fetal survival in patients without history of vascular thrombosis (84.6 vs 66.4%; p = 0.11).

CONCLUSION

Obstetrical prognosis in APS was improved by antithrombotic therapy. Studies are needed to define individual risk and specific significance of the various antiphospholipid antibodies, in order to improve the respective indications for aspirin alone or with heparin in women without thrombotic events.

The role of B-mode ultrasonography and electron beam computed tomography in evaluation of Takayasu's arteritis: a study of 43 patients

OBJECTIVES

To evaluate the capacity of B-Mode ultrasonography (B-Mode US) and electron-beam computed tomography (EBCT) to detect arterial changes in Takayasu's arteritis.

METHODS

EBCT angiography of the thoracoabdominal aorta and pulmonary artery, and B-mode US of large superficial arteries (common carotid, subclavian, and common femoral arteries) were performed prospectively in 43 consecutive patients with established Takayasu's arteritis. The arterial wall thickness was measured, and lumen changes (stenosis, aneurysm) were noted.

RESULTS

The combined results of B-Mode US and EBCT examinations showed that every patient had at least one abnormality at the studied sites. The median score of abnormal sites was 7. The most frequent lesion was a characteristic long, homogeneous, circumferential thickening, visualized in 52% of examined sites and in all patients but one (98%). Stenosis was detected by US and by EBCT, respectively, in 44% and 32% of patients, and aneurysm in 0.4% and 68%.

CONCLUSIONS

In Takayasu's arteritis, B-Mode US and EBCT was able to visualize the classical caliber abnormalities (stenosis, aneurysm) and, in contrast to angiography, to depict vessel wall thickening, a major pathologic feature of the disease. Both these safe techniques seem more useful than angiography to characterize and map the vascular lesions of Takayasu's arteritis.

[Giant cell myocarditis. Report of a case]

The authors report a case of giant cell myocarditis leading to rapidly progressive cardiac failure despite immuno-suppressor treatment in a 20 year old woman. The cardiac failure was successfully managed by implantation of a left ventricular assist device and then cardiac transplantation. The problems encountered underline the importance of accurate diagnosis by endomyocardial biopsy before undertaking treatment and the difficulties in the choice of appropriate method of assistance in this indication. Giant cell myocarditis is a rare cause of cardiac failure and should be considered in the differential diagnosis in view of its clinical features and risk of progression. The literature and the therapeutic implications are discussed.

Ribavirin in hepatitis C related cryoglobulinemia

OBJECTIVE

An open, uncontrolled trial of ribavirin, an oral guanosine nucleoside analog for treatment of hepatitis C, in patients with hepatitis C virus (HCV) associated cryoglobulinemia intolerant to interferon.

METHODS

Five patients with cryoglobulinemia related to HCV infection unresponsive to interferon therapy received oral ribavirin (100 to 1200 mg daily) for 10 to 36 months.

RESULTS

Patients treated with ribavirin had prompt decrease in serum aminotransferase levels and marked improvement of manifestations of cryoglobulinemia within a few weeks. Ribavirin did not eradicate HCV RNA from the sera, but a decrease in viral load was observed in 3 patients, from 232 to 86 x 10(5) copies HCV/ml. Relapse occurred within 3 months once therapy was discontinued. The drug was well tolerated, but mild dose related hemolysis was common.

CONCLUSION

Ribavirin monotherapy may be effective in patients with symptomatic cryoglobulinemia related to HCV infection, but this effect is not sustained when ribavirin therapy is discontinued.

Pregnancy in relapsing polychondritis: twenty-five pregnancies in eleven patients

OBJECTIVE

To determine maternal and fetal outcome in pregnant women with relapsing polychondritis (RP).

METHODS

Retrospective review of 11 records selected from among those of 116 female RP (Michet's criteria) patients.

RESULTS

In these 11 women, 25 pregnancies occurred after or concomitantly with the onset of RP. The mean (+/- SD) age at RP onset was 25 +/- 5 years (range 15-31). Therapeutic abortion was performed in 1 woman because of ongoing cyclophosphamide treatment. Disease flare occurred in 7 of 24 pregnancies, requiring treatment modification in 2 cases. RP was considered stable in 16 and asymptomatic in 1 of the 24. Treatment of RP was with nonsteroidal antiinflammatory drugs (2 of 24), steroids (13 of 24), dapsone (7 of 24), or plasma exchanges (1 of 24); no treatment was given in 8 of the 24 pregnancies. In 14 pregnancies, the course was uneventful. Ten pregnancies were complicated by ectopic nidation (n = 3), spontaneous abortion (n = 3), premature birth (n = 3), and premature rupture of membranes (n = 1). Eighteen normal children were born.

CONCLUSION

Pregnancy does not seem to modify the course of RP. Successful pregnancies may be achieved in women with RP. No RP was observed in the neonates.

Endomyocardial fibrosis in Behçet's disease

OBJECTIVE

To report on four patients with Behçet's disease associated with endomyocardial fibrosis involving the right or the left ventricle.

METHODS

Charts of more than 350 patients with Behçet's disease were reviewed. Endomyocardial fibrosis was confirmed because of cardiac failure in three patients and incidentally discovered by histological examination of an operative specimen in one patient. Echocardiography displayed bright echogen endocardium. Angiocardiography showed a reduced ventricular size. Electron beam computed tomography demonstrated a lowdense area involving the endocardium. Magnetic resonance imaging showed a mass of intermediate intensity on T1 weighted images. Diagnosis of endomyocardial fibrosis was based on histological study of a biopsy specimen in one patient and of an operative specimen in three.

RESULTS

Six other similar cases of endomyocardial fibrosis complicating Behçet's disease were previously reported in the medical literature. Endomyocardial fibrosis predominantly involved the right ventricle. It can be considered a feature of Behçet's disease because: (a) no other cause was discovered; (b) arteritis, valvulopathy, and intraventricular thrombus were closely linked, and (c) all patients with endomyocardial fibrosis had vasculo-Behçet pattern.

CONCLUSION

Endomyocardial fibrosis may be the sequelae of vasculitis involving endocardium or myocardium, or both and complicated with intraventricular thrombosis. Behçet's disease should be added to the list of causes of endomyocardial fibrosis.

Systemic vasculitis and myelodysplastic syndromes. A report of two cases

Two cases of systemic vasculitis associated with myelodysplastic syndromes are reported. Vasculitis may develop either before or after the diagnosis of a hematologic disorder, and it responds to treatment with high-dose corticosteroids.

Arterial lesions in Behçet's disease. A study in 25 patients

OBJECTIVE

To identify the prognostic indicators of patients with Behçet's disease complicated with arterial lesions.

METHODS

Retrospective chart analysis of 25 consecutive patients with Behçet's disease and angiographically proven arterial lesions.

RESULTS

Occlusive lesions were present in 7 patients, aneurysms in 3, and both occlusive and aneurysmal lesions in 15. High dose corticosteroids were not effective in isolated occlusive lesions and probably contributed to one fatal infection. Death was related to aneurysms in 5 patients. Twenty-seven vascular surgical procedures were performed in 15 patients. Arterial lesions recurred in all patients who did not received postoperative corticosteroids. Within a 2 yr period after operation, the rate of therapy failure was lower in the group of patients treated with a postoperative combination of corticosteroids and immunosuppressive drugs, compared to the group treated with corticosteroids alone. In patients treated for lower limb arterial lesions, the rate of relapse was similar whether venous autologous or prosthetic grafts were used. Graft thrombosis occurred in 3/7 patients given anticoagulants and in 3/4 patients with no antiaggregant or anticoagulant therapy.

CONCLUSION

Aneurysms have a worse prognosis than occlusive lesions. High dose corticosteroids should not be systematically prescribed for isolated occlusive lesions. Surgery, when feasible, is indicated for aneurysms because they entail a high risk of rupture. Postoperative corticosteroids are necessary to prevent arterial relapse. A combination of corticosteroids and immunosuppressive therapy is more effective than corticosteroids alone. After bypass for lower limb arterial lesions, anticoagulation is warranted to prevent graft thrombosis.

Urogenital manifestations of Wegener granulomatosis

We report 8 patients with Wegener granulomatosis (WG) who suffered from symptomatic urogenital involvement including acute urinary retention related to prostatitis, orchitis, ureteral stenosis, bladder pseudotumor, and penile ulceration. Urogenital manifestations occurred as an isolated manifestation of WG in 4 patients, at the onset of the disease in 1 patient, and as the only symptom of relapse in 3. Data used to distinguish specific WG involvement from infection or cyclophosphamide urothelial toxicity are discussed. Four patients needed a surgical procedure consisting of suprapubic cystostomy for acute urinary retention, bilateral ureteral double J stents for bilateral ureteral stenosis, and prostate transurethral resection. Urogenital symptoms promptly resolved with medical therapy. High-dose corticosteroids and immunosuppressive drugs should be used as first-line therapy to avoid unnecessary surgery.

Pregnancy and its outcome in systemic lupus erythematosus

In a multi-centre prospective study of systemic lupus erythematosus and pregnancy in France, 117 cases were identified from 1987 to 1992. We report significant morbidity and mortality for mother and fetus from an analysis of 103 cases. Pregnancy outcome was as follows: 28 full-term births, 48 premature births, 18 fetal losses (13 early and two late spontaneous abortions, three stillbirths), five therapeutic abortions and four elective abortions (for unwanted pregnancy). Four preterm neonates died. Lupus was active at pregnancy onset in 28 patients. Of 75 patients with inactive lupus at conception, 27 relapsed during pregnancy, and seven postpartum. Two patients with nephrotic syndrome treated with high-dose corticosteroids died from opportunistic infections. Fetal loss correlated with a history of proteinuria and absence of anti-SSA antibodies. Prematurity was related to a history of fetal loss, active lupus at pregnancy onset, hypertension and > or = 20 mg/day prednisone during pregnancy. Intrauterine growth retardation correlated with pregnancy of short duration, low serum C3 or C4, hypertension, and absence of SSA antibodies. Three of 22 newborns whose mothers had anti-SSA antibodies developed neonatal lupus: two with cutaneous involvement and one with complete atrioventricular block.

Intravenous gamma globulin as first line therapy in polymyositis and dermatomyositis: an open study in 11 adult patients

OBJECTIVE

Polymyositis (PM) and dermatomyositis (DM) are inflammatory muscle diseases of presumed autoimmune origin. Many possible interventions are available to treat these patients: corticosteroids, immunosuppressive drugs, plasmapheresis, and total body irradiation. But these therapies are not always effective and may be responsible for certain serious side effects. Polyvalent intravenous immunoglobulin (IVIG) has been tried with success in inflammatory myopathies after failure of traditional treatment. An attempt was made to evaluate the efficacy of IVIG as first line therapy in patients with PM or DM.

METHODS

Eleven Caucasian patients [6 women, 5 men, mean age 55.6 (SD 10.1) years], with active recent inflammatory myopathy, were treated by high doses of IVIG as first choice. The average duration of inflammatory myopathy before IVIG was 9.6 months (SD 10.2 months, with a range of 1 month to 3 years). Five patients had PM and 6 had DM. None had myositis associated with connective tissue disease. Two patients had a history of malignant disease: 1 lymphoma and 1 breast tumor with relapse of the malignancy during the study. One patient had a probable lung carcinoma and in another patient, ovarian carcinoma was diagnosed a few months after the onset of IVIG. We used preparations of polyvalent human i.v. gamma globulins with intact IgG. All patients received 1 g/kg daily for 2 days each month. The mean course of treatment was 4 months.

RESULTS

Clinical assessment, evaluated by proximal muscle power and biochemical tests, was carried out before each treatment period. Significant clinical improvement was noted in only 3 of the 11 patients (one with acute coxsackie virus B infection, and one with possible drug induced myopathy). Mean muscle power estimated for the 11 patients before and after IVIG therapy was not significantly improved. Eight patients showed significant biochemical improvement (more than 50%). Mean CK levels for the 11 patients showed a statistically significant decrease during IVIG therapy (p < 0.01). Minor IVIG side effects were noted in one patient.

CONCLUSION

IVIG therapy seems effective rarely as first therapy in patients with inflammatory myopathy but may be considered especially in viral or drug induced myopathy. IVIG therapy as the first treatment may also be tried in patients with contraindication for steroids, and in mild myopathy, especially in the elderly, to avoid steroid induced side effects.

Dermatomyositis and ovarian cancer: a report of 7 cases and literature review

The relationship between malignancy and inflammatory myopathies is now statistically well established. However, the link between polymyositis (PM) or dermatomyositis (DM) and ovarian cancer (OC) has never been clearly emphasized. OC is the 6th most frequent malignancy, occurring in about 1% of the general female population. We describe 7 cases of DM associated with OC (proven in 6 patients, and very probable in a 7th), in a series of 140 adult inflammatory myopathies followed in our institution [84 PM and 56 DM (including 45 female)]. Twenty-four patients had associated malignancy (12 PM and 12 DM). Without considering the probable case, OC occurred in 13.3% (6/45) of the total female DM population, a much higher rate than the 1% observed in the general female population; and in 21.4% (6/28) of females aged over 40 with DM. In women over 40 with DM, ovarian cancer has a major position among associated internal malignancies, and has to be adequately looked for by physicians.

Malignant hypertension in antiphospholipid syndrome without overt lupus nephritis

The antiphospholipid syndrome is usually defined by the association of a clinical manifestation (recurrent venous and/or arterial thrombosis, recurrent spontaneous miscarriages) and a biological abnormality (anticardiolipin antibody, lupus anticoagulant). We retrospectively analyzed the records of 5 patients (4 females, 1 male, aged 30 +/- 12 years) with antiphospholipid syndrome, primary (n = 1) or secondary to systemic lupus erythematosus (n = 4), who developed malignant systemic hypertension with renal insufficiency, in the absence of lupus nephritis. Before the episode of malignant hypertension, all patients had normal systemic blood pressure and renal function. During malignant hypertension the systolic pressure was 206 +/- 39 mmHg and the diastolic pressure 130 +/- 25 mmHg, peak serum creatinine was 204 +/- 95 mumol/l, daily proteinuria was 1.1 +/- 0.8 gr, and complement serum levels were normal in all patients. Renal angiography found normal proximal renal arteries. Renal biopsy showed ischaemic glomeruli without proliferative lesions (n = 5), focal intimal fibrosis either isolated (n = 3) or associated with thrombosis (n = 2) of the intrarenal vessels, and the absence of vasculitis. Immunofluorescence study did not reveal typical lupus deposits. Patients were treated with antihypertensive agents, increasing doses of prednisone (n = 3), and anticoagulant (n = 2) or anti-aggregant therapy (n = 1). After a mean follow-up of 6.8 +/- 5.2 years, 4 patients were still alive with normal blood pressure and renal function, whereas 1 patient died of a probable catastrophic antiphospholipid syndrome. Patients with antiphospholipid syndrome, primary or secondary to systemic lupus erythematosus, may develop malignant hypertension with renal insufficiency and intrarenal vascular lesions, in the absence of lupus nephritis.